RESEARCH ARTICLE

Longevity and marginal bone loss of narrow-

diameter implants supporting single crowns:
A systematic review
Lucas Henrique Telles1, Fernando Freitas Portella ID1,2, Elken Gomes Rivaldo1*

1 Programa de Pós-Graduação em Odontologia, Universidade Luterana do Brasil, Canoas, RS, Brazil,

2 Universidade Feevale, Novo Hamburgo, RS, Brazil

* elkenrivaldo@gmail.com

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a1111111111 Abstract
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Purpose
To compare the longevity and marginal bone loss of narrow-diameter (�3.3-mm) versus
standard-diameter implants supporting single crowns.
OPEN ACCESS

Citation: Telles LH, Portella FF, Rivaldo EG (2019)
Longevity and marginal bone loss of narrow-
diameter implants supporting single crowns: A
systematic review. PLoS ONE 14(11): e0225046.
https://doi.org/10.1371/journal.pone.0225046
Editor: Sompop Bencharit, Virginia Commonwealth
University, UNITED STATES
Material and methods
The MEDLINE (via PubMed), Scopus, and SciELO databases were searched for relevant
publications. In addition, the scientific references provided by each of the implant companies
that appeared in the search were reviewed. Intervention studies comparing longevity and
bone loss between narrow-diameter and standard-diameter implants were included.

Received: August 7, 2019

Results
Accepted: October 28, 2019
The search was limited to in vivo studies in humans. The query returned 1931 results, of
Published: November 11, 2019
which 4 met the inclusion criteria. The implant success rate ranged from 93.8% to 100%
Peer Review History: PLOS recognizes the over a maximum follow-up of 3 years, with no difference between narrow- and standard-
benefits of transparency in the peer review
diameter implants. Meta-analysis of all included studies showed greater bone loss in nar-
process; therefore, we enable the publication of
all of the content of peer review and author row-diameter implants as compared with standard ones; however, when analysis was
responses alongside final, published articles. The restricted to randomized trials, no such difference was present.
editorial history of this article is available here:
https://doi.org/10.1371/journal.pone.0225046

Copyright: © 2019 Telles et al. This is an open Conclusion

access article distributed under the terms of the The meta-analysis showed no difference in longevity between narrow implants and standard
Creative Commons Attribution License, which
implants when supporting single crowns. However, narrow-diameter implants may be asso-
permits unrestricted use, distribution, and
reproduction in any medium, provided the original ciated with greater marginal bone loss. These findings should be regarded cautiously due to
author and source are credited. the short follow-up duration and methodological heterogeneity of the primary studies.
Data Availability Statement: All relevant data are
within the manuscript and its Supporting
Information files.

PLOS ONE | https://doi.org/10.1371/journal.pone.0225046 November 11, 2019 1 / 12


Funding: The funders had no role in study design,
data collection and analysis, decision to publish, or
preparation of the manuscript.
Competing interests: The authors have declared
that no competing interests exist.
PLOS ONE | https://doi.org/10.1371/journal.pone.0225046 November 11, 2019
Longevity and bone loss of narrow implants
Introduction
Narrow-diameter implants (<3.3 mm) were designed for edentulous sites with reduced mesio-
distal space, such as mandibular central and lateral incisors, as well as maxillary lateral incisors.
The current literature supports their extended use in other clinical situations as well, such as
narrow alveolar ridges, to prevent preoperative or intraoperative bone reconstruction [1,2]
(which increase treatment cost and duration [3,4]) and to reduce postoperative morbidity.
However, commercially pure titanium (cpTi) has limited mechanical strength, which led to
the hypothesis that the use of narrow-diameter implants could pose a risk of fracture of the
implant body [5,6]. Advances in biomaterials led to the development of alloys with increasing
fracture and fatigue resistance, such as an alloy of titanium and zirconium (83–87% titanium
added to 13–17% zirconium [7]). Biomechanical assays of this alloy in experimental models
demonstrated increased resistance to the stresses generated by occlusal loading compared to
cpTi [3], even at smaller-than-conventional diameters.
Observational studies have shown that narrow-diameter implants have comparable longev-
ity to standard implants [8,9]. In addition, when the longevity of narrow-diameter and stan-
dard implants was compared, that of implants with a diameter of 3.0–3.25 mm was found not
to differ from that of standard-diameter implants [4,10]. Nonetheless, this finding is based pre-
dominantly on observational studies, and does not distinguish between different types of pros-
thetics supported by these implants. Thus, it does not answer the question of whether
practitioners can choose to place narrow-diameter implants instead of conventional ones for
the rehabilitation of single missing teeth. Furthermore, there is no consensus on the influence
of implant diameter on marginal bone loss. The present review focused on a problem not pre-
viously addressed in the literature: narrow-diameter implants (those implants with a diameter
of 3.3 mm or less) supporting only single crowns. Within this context, the present systematic
review was designed to compare longevity and marginal bone loss between narrow-diameter
and standard-diameter implants supporting single crowns.
Methods
The present systematic review was registered in the PROSPERO platform (CRD42018117261)
and reported in accordance with the PRISMA statement [11]. The guiding research question
for this study was “Is there a difference in longevity and marginal bone loss between narrow-
diameter and standard-diameter implants when supporting single crowns in healthy
patients?”. In PICO format, this question may be phrased as follows:
P–healthy patients;
I–implants supporting single crowns;
C–narrow-diameter versus standard-diameter implants;
O–longevity of implant and marginal bone loss.
Eligibility criteria
Publications that met the following eligibility criteria were included:
a. intervention studies in humans which evaluated the longevity of implants retaining single
crowns; observational prospective studies were not included.
b. with at least one group of patients which received narrow-diameter implants and one
group which received standard-diameter implants, with a minimum of 10 participants in
each group;
2 / 12
 Longevity and bone loss of narrow implants

c. which reported implant longevity over a follow-up period of at least 1 year.

There were no restrictions on language or date of publication.

Sources and search strategy

The MEDLINE (via PubMed), Scopus, and SciELO databases were searched through Decem-
ber 2018. The search strategy for each database is described below.
PubMed: (("dental implant" OR "dental implants" OR "narrow implant" OR "narrow
implants" OR "narrow-diameter implant" OR "narrow-diameter implants")) AND (longevity
OR survival OR “follow-up” OR success)) AND ("randomized controlled trial" OR RCT OR
"clinical study" OR trial OR “clinical research” OR “longitudinal study” OR “cohort study” OR
practice-based);
Scopus: (TITLE-ABS-KEY ("dental implant" OR "dental implants" OR "narrow implant"
OR "narrow implants" OR "narrow-diameter implant" OR "narrow-diameter implants") AND
TITLE-ABS-KEY (longevity OR survival OR "follow-up" OR success) AND TITLE-ABS-KEY
("randomized controlled trial" OR rct OR "clinical study" OR trial OR "clinical research" OR
"longitudinal study" OR "cohort study" OR practice-based));
SciELO: “dental implants”;
In addition to the aforementioned electronic databases, the scientific literature recom-
mended by implant manufacturers as a reference on their products was also reviewed. The fol-
lowing manufacturers were included: Straumann (Switzerland), Nobel Biocare (Switzerland),
Biohorizons (USA), Z-systems (Germany), Dentsply (USA), 3i (USA), and Dentatus
(Sweden).

Study selection and data collection process

The article lists retrieved by each search strategy were unified and duplicate entries removed.
For study selection, two investigators (LHT and EGR) evaluated the titles and abstracts sepa-
rately. Those considered ineligible by both reviewers were excluded outright; those considered
ineligible by one reviewer but eligible by the other were retained for full-text reading.
All studies not excluded were read in full by two investigators working together (LHT and
FFP), who then selected those that fully met the eligibility criteria and performed data extrac-
tion. At this time, the authors also performed the risk of bias analysis. Patient-related and pro-
cedure-related data were collected, as were the outcomes of interest (longevity and marginal
bone loss).
Longevity was determined by the percentage of implants considered successful at the latest
recorded time point of clinical evaluation. Implants were considered successful when they
were osseointegrated and remained functional. Marginal bone loss data were collected when
assessed by radiographic examination; mean values for implant sites were calculated for analy-
sis. To perform sensitivity analysis, the number of implants that were not followed in each
experimental group was recorded, and longevity was then recalculated. When more than one
publication was derived from a single study, with different follow-up periods for the same sam-
ple, data from all publications referring to the same study were pooled and the publication
with the longest duration of follow-up was recorded in the table.

Risk of bias in individual studies

Studies were assessed for risk of bias as recommended in the Cochrane Handbook of Systematic
Reviews of Interventions. The possibility of conflict of interest with implant manufacturers was
also considered and recorded.

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 Longevity and bone loss of narrow implants

Data synthesis and analysis

Implant longevity was recorded as the number of successful cases followed in relation to the
total number of cases in each group. Marginal bone loss around the implant head was
extracted in mm for each of the experimental groups.
The outcomes of the included articles were pooled for meta-analysis to determine the over-
all estimated effects of each outcome based on a random effects model. For analysis of longev-
ity, the Mantel-Haenszel method was applied to calculate the risk ratio for success, while for
marginal bone loss, the overall mean difference was calculated. Statistical analysis was per-
formed in RevMan 5.3 software (The Cochrane Collaboration). Significance was accepted at
the 5% level.

Results
Study selection
Fig 1 provides a flow diagram of study selection. The database search (PubMed, Scopus, and
SciELO) retrieved 6,402 articles. A hand search of the reference lists provided by manufactur-
ers yielded a further 1,677. After exclusion of duplicate entries, 1,931 papers remained. Of

Fig 1. Flow diagram of study selection.

https://doi.org/10.1371/journal.pone.0225046.g001

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 Longevity and bone loss of narrow implants

Table 1. Characteristics of the studies and detailed description of comparison groups.

Study Andersen (2001) [4] Santing (2013) [14] Ioannidis (2015) [8,12] de Souza (2018) [13]
Narrow Standard Narrow Standard Narrow Standard Narrow Standard
No. patients 28 27 12 48 20 20 22 22
Mean age (years) 23.2 23.0 36.9 Not reported 53.4
No. implants 32 28 12 48 20 20 22 22
Diameter 3.25 3.75 3.3 4.1 3.3 4.1 3.3 4.1
Length 13 and 15 13 and 15 12 and 14 12 and 14 �8 �8 6 to 12 8 to 10
Implant site Anterior maxilla Anterior maxilla Anterior or posterior, maxilla or Posterior, maxilla or mandible
mandible
Manufacturer 3i (2-piece) Straumann (2-piece) Straumann (2-piece) Straumann (2-piece)
Platform type Platform matching Platform switching Platform switching Platform matching
Apical-coronal Bone level Bone level Bone level Tissue level
implant position
Implant material Titanium Titanium- Zirconium Titanium- Zirconium /Titanium Titanium- Zirconium /Titanium
/Titanium
Surface treatment No Yes Yes Yes
Time to loading 6 months 3 months 3 months Not reported
Duration of follow- 3 years 1.5 year 3 years 3 years
up
Success rate at latest 93.8% 100% 100% 100% 100% 100% 95.4% 100%
follow-up
Outcome of followed 27 successful, 3 26 successful, 2 All 12 All 48 17 successful, 3 15 successful, 5 19 successful, 2 lost 20 successful, 2
implants lost to follow-up lost to follow-up successful successful lost to follow-up lost to follow-up to follow-up, 1 lost to follow-up
failed
Radiographic 0.52±0.01 0.40±0.16 Not reported 0.40±0.93 0.31±0.59 0.58±0.39 0.53±0.46
marginal bone loss
(mm)
https://doi.org/10.1371/journal.pone.0225046.t001

these, 1,819 were excluded after analysis of titles and abstracts. Thus, 112 articles were read in
full. None of these was found only on manufacturers’ reference lists. After full-text reading,
107 papers were removed for failure to meet the eligibility criteria. Of the 5 eligible articles
remaining, two were from the same study, but with different follow-up times [8,12]). The 4
remaining articles were included in the meta-analysis (Table 1).

Study characteristics
De Souza et al [13]. conducted a split-mouth randomized clinical trial in which patients
received Tissue Level implants (Straumann, Switzerland) with a diameter of 3.3 mm at one site
and 4.1 mm in another. Each patient received at least one implant of each diameter in the max-
illa or mandible, for a total of 44 implants placed (22 narrow and 22 standard). Periapical
radiographs were performed on the day of placement and at 1-year and 3-year follow-up. The
authors found no significant differences in marginal bone loss at any of the three follow-up
time points (immediate, 1 year, and 3 years). After 3 years of follow-up, the success rate was
100% for standard-diameter implants and 95.4% for narrow-diameter implants. One implant
presented a pocket depth >5 mm, with bleeding on probing and suppuration. Nevertheless,
the implant remained in position and functional, for a 100% survival rate in the narrow-diam-
eter group.
Santing et al [14] carried out a prospective intervention study using Bone Level implants
(Straumann, Switzerland) for single-tooth replacement in the maxilla. Sixty patients partici-
pated in the study, with each receiving a 3.3-mm (narrow) or 4.1-mm (standard) implant.

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 Longevity and bone loss of narrow implants

Overall, 12 narrow and 48 standard implants were placed. The authors compared bone loss on
periapical radiographs between implants placed in augmented sites and those placed in native
bone. There was no significant difference between groups, with a 100% survival rate at a maxi-
mum follow-up time of 18 months.
In a randomized clinical trial, Ioannidis et al [8,12] sought to compare loss of marginal
bone level with 3.3-mm versus 4.1-mm implants. Implants in the experiment group (n = 20)
were made from a Ti-Zr alloy, while those in the control group (n = 20) used conventional tita-
nium alloys. The implants were placed randomly at sites requiring single tooth replacement, at
any location in the maxilla or mandible, and were followed for up to 3 years. At 1-year follow-
up, all evaluated implants were in place and stable; two participants in the control group were
subsequently lost to follow-up. At the end of follow-up, 32 of the 40 included patients were
examined (15 control, 17 experiment). The other 8 patients were lost to follow-up. According
to the authors, there were no implant failures, giving a 100% survival rate for both groups over
3 years (among the implants examined at final follow-up).
A clinical trial by Andersen et al.[4] included 55 patients requiring single-tooth replace-
ments in the anterior region of the maxilla. Of these, 27 received 28 standard implants (diame-
ter 3.75 mm), and 28 patients received 32 narrow implants (diameter 3.25 mm). Two implants
in the narrow-diameter group were lost (93.8% survival rate), versus none in the standard
group (100%).

Synthesis of results
A meta-analysis considering those intervention studies (Fig 2) that allowed comparison of lon-
gevity between narrow and standard implants showed no difference between them (RR 0.98
[0.90, 1.07]). A sensitivity analysis including only the RCT (Fig 3) showed a similar risk ratio
for success among distinct diameters, with a slight increase in the 95% confidence interval (RR
1.00 [0.84, 1.20]).
Narrow implants were associated with greater marginal bone loss, with a mean 0.12 (0.06 to
0.18) mm of additional loss compared to standard implants (Fig 4). This difference did not
remain when only RCTs were included in the meta-analysis (Fig 5), the mean difference in
bone loss then being 0.06 (-0.18 to 0.30) mm.

Risk of bias
Fig 6 summarizes the analysis of risk of bias in the included studies. None of the studies
included all of the quality categories evaluated; blinding of assessors and patients was most
often neglected. Three of the four studies had some form of relationship with the industry.
Funnel plots analyses showed a low risk of publication bias, while the I2 value of 0% was con-
sistent with absence of statistical heterogeneity among studies, both for longevity and for mar-
ginal bone loss.

Fig 2. Forest plot of all intervention studies comparing the longevity of narrow and standard implants.
https://doi.org/10.1371/journal.pone.0225046.g002

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 Longevity and bone loss of narrow implants

Fig 3. Forest plot of randomized clinical trials comparing the longevity of narrow and standard implants.
https://doi.org/10.1371/journal.pone.0225046.g003

Discussion
The present literature review and meta-analysis was designed to help dental practitioners
decide which implant diameter to choose in settings that would allow placement of both nar-
row-diameter and standard implants to support single crowns. Despite the short follow-up
period of 3 years or less, longevity was shown not to differ between diameters. However, nar-
row-diameter implants may be associated with greater marginal bone loss—0.12 (0.06–0.18)
mm greater at 3-year follow-up. It bears stressing that the evaluation of implant success goes
beyond longevity. Several extrinsic and intrinsic variables may be implicated in peri-implant
marginal bone loss. Factors related to the implant itself include its geometry, dimensions and
interface between the prosthetic abutment and the implant, the three-dimensional position of
the implant, and its angle. Patient-related factors include the quantity and quality of hard and
soft tissue surrounding the implant, which are involved in maintaining the biological distances
between tooth and implant and from implant to implant [1].
The amount of bone tissue surrounding a narrow-diameter implant was likely to be smaller
than when placing a standard implant in the non-randomized studies included in this system-
atic review. This would justify the greater marginal bone loss with narrow-diameter implants.
A randomized clinical trial comparing the amount of peri-implant bone through postoperative
CBCT could provide further evidence to support or refute this assumption. In addition to
implant diameter, the type of platform and the position of the implant-abutment junction [15]
can also influence marginal bone loss. A systematic review comparing marginal bone loss with
platform-switching versus platform-matching implants, which pooled the outcomes of 15 pub-
lications with data from 642 patients followed up for 1 year, suggested greater bone loss with
platform matching [16]. Among the three studies included in the analysis of marginal bone
loss in this review, Andersen [4] reported higher values for narrow implants, which accounted
for the statistical difference observed in the meta-analysis that included all eligible intervention
studies. A stratified analysis, evaluating the joint effect of implant diameter and of different
implant platforms and apicocoronal positions, is necessary for a better understanding of the
factors associated with marginal bone loss.
The included studies reported on implants placed in different regions of the oral cavity.
Santing et al. [14] reported on implants placed in the anterior and first premolar regions, while

Fig 4. Forest plot of all intervention studies comparing marginal bone loss between narrow and standard implants.
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 Longevity and bone loss of narrow implants

Fig 5. Forest plot of randomized clinical trials comparing marginal bone loss between narrow and standard implants.
https://doi.org/10.1371/journal.pone.0225046.g005

de Souza et al. [13] placed implants only in the posterior region. Ioannidis et al [8,12] placed
implants in the anterior and premolar area, and Andersen et al. [4], in the anterior maxilla.
This variability hindered analysis of the potential impact of implant location. Another aspect

Fig 6. Risk of bias of included studies.

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 Longevity and bone loss of narrow implants

to be considered in the data analysis is the reason for tooth loss. Of the articles included in this
review, only Santing et al. reported this information; the most frequent cause in their series
was tooth fracture (n = 29), followed by endodontic failure (n = 19), root resorption (n = 5),
periodontal disease (n = 4) and agenesis (n = 3). Andersen et al. [4] performed immediate pro-
visionalization in the narrow implants. Although there is concern about the incidence of mas-
ticatory forces on the implants immediately after placement, clinical maneuvers to minimize
osseointegration failure and marginal bone loss may be employed regardless of implant diame-
ter [17]. These unique characteristics of the different included studies should be considered
when analyzing the results of this meta-analysis.
Longevity or success can be assessed from several aspects [18]. In this review, the criteria
for implant longevity were osseointegration and preserved function at clinical evaluation.
Implant failures reported in primary studies occur most often in the earliest stage of follow-up
(first 6 months), mainly during the process of osseointegration. After this initial period, there
were practically no implant failures. However, the narrow implants were associated with
greater marginal bone loss, which clinically, in the long term, may represent a concern to the
clinician, considering the possibility of cosmetic issues such as retraction of the peri-implant
mucosa due to decreased bone support, as well as facilitating the development of peri-implan-
titis [19].
A previous systematic review with meta-analysis published addressing the comparison nar-
row-diameter (�3.3-mm) versus standard-diameter implants [20,21]. In general, these studies
showed no difference in longevity and marginal bone loss between diameters. These previous
studies grouped implants without distinction as to the type of prosthesis supported. Their sur-
vival data were also mixed, referring to narrow implants rehabilitating fully edentulous arches
(i.e., supporting removable or fixed complete dentures), as well as partially edentulous ones
(supporting removable partial dentures, fixed partial dentures, and single crowns). Further-
more, observational studies were grouped with interventional studies. The decision to limit
this systematic review to implants of 3.3 mm or narrower diameter and supporting single
crowns only aimed to present clinicians with data on the survival of these biomaterials, which
provide advantages such as less need for alveolar ridge augmentation prior to implant place-
ment, less need for orthodontic movement to recover reduced prosthetic spaces, and improved
aesthetic outcomes in the anterior zone [22] enhancing the quality of peri-implant tissues.
Another, more recent review [23] also focused on studies of narrow implants, comparing these
with standard-diameter implants, and including subgroup analyses stratified by diameter (<3
mm, <3.0–3.25 mm, and 3.3–3.5 mm). This review found that the longevity of implants less
than 3.0 mm in diameter was shorter than that of standard implants. However, this review also
failed to discriminate between implants as to the type of prosthesis supported (single or multi-
ple, fixed or removable). Non-splinted implants are subject to greater overload than those
splinted by prosthetic structures [24]. Furthermore, we present a meta-analysis of marginal
bone loss.
We chose to conduct our analysis considering implants lost to follow-up as failures and
then recalculate longevity, in order to complete a sensitivity analysis, seeking to attenuate any
reporting bias. However, considering the longevity reported by the authors of the primary
studies, without sensitivity analysis, the effect size measures of the meta-analyses would remain
similar, with a risk ratio for success of narrow implants of 0.98 [0.92, 1.03]. Such sensitivity
analyses are of the utmost importance when studying treatment longevity, since patient losses
to follow-up can have a significant impact on estimated longevity. Considering the success rate
of narrow-diameter implants in observational studies, a sensitivity analysis considering losses
to follow-up might reduce success rates from nearly 100% to less than 90% [4,12,13,25].

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 Longevity and bone loss of narrow implants

The studies were heterogeneous, with differences in design, implant manufacturers,

implant sites (anterior versus posterior, maxilla versus mandible), implant diameters com-
pared, and time to implant loading. It is plausible that some difference in implant longevity
would exist as a result of certain variables; however, we were unable to isolate these. In addi-
tion, quality evaluation of the studies revealed potential risk of bias, due to issues such as inade-
quate randomization, absence of allocation concealment or assessor blinding, and industry
involvement in all included studies. Due to the inclusion criteria adopted, which restricted the
review to intervention studies (not necessarily randomized clinical trials), the absence of ran-
dom allocation was expected. The selection bias caused by the inclusion of non-randomized
studies, besides the methodological heterogeneity of the studies, means that caution is war-
ranted when translating the results of this review into clinical practice. One example is analysis
of marginal bone loss, the results of which differed when all studies were included and when
analysis was restricted to RCTs.
We decided to include non-randomized intervention studies because of the nature of the
research question. It was expected that, in primary studies, allocation of patients into the nar-
row-diameter and standard-diameter groups would occur according to the characteristics of
the enrolled patients, such as the space available for prosthetic rehabilitation, and not by ran-
domization. Thus, the presence of non-randomized comparative studies was expected, and
their inclusion allowed us to better answer our research question in this poorly studied con-
text. Nevertheless, on meta-analysis, no evidence of statistical heterogeneity was observed (I2 =
0.00), thus allowing the data to be compiled for analysis.
Incorrect three-dimensional positioning of the implant in the alveolar ridge can lead to
physiological bone loss. The coronal portion of bone tends to undergo resorption if the
implant is placed too close to neighboring teeth, to other implants, or to a very thin bony wall,
as is usually the case with the buccal bone plate [16]. This would justify the practitioner’s deci-
sion to place an implant with a narrower diameter, in an attempt to maintain a thicker portion
of bone tissue around the implant or avoid undue proximity to neighboring teeth or appli-
ances, in order to minimize or mitigate unnecessary resorption.
The meta-analysis showed no difference in longevity between narrow implants and stan-
dard implants when supporting single crowns. However, narrow-diameter implants may be
associated with greater marginal bone loss. These findings should be regarded cautiously, due
to the short follow-up duration and methodological heterogeneity of the primary studies. Fur-
ther studies should address these aspects in greater detail.

Supporting information
S1 PRISMA Checklist.
(PDF)

Acknowledgments
The authors thank Professors Carlos Alberto Feldens, Gustavo Frainer Barbosa, and Otacı́lio
Luı́s Chagas Júnior for their important suggestions during the conduction of this study.

Author Contributions
Conceptualization: Lucas Henrique Telles, Fernando Freitas Portella, Elken Gomes Rivaldo.
Data curation: Lucas Henrique Telles, Fernando Freitas Portella, Elken Gomes Rivaldo.
Formal analysis: Lucas Henrique Telles, Fernando Freitas Portella, Elken Gomes Rivaldo.

PLOS ONE | https://doi.org/10.1371/journal.pone.0225046 November 11, 2019 10 / 12

 Longevity and bone loss of narrow implants

Funding acquisition: Lucas Henrique Telles, Fernando Freitas Portella, Elken Gomes Rivaldo.
Investigation: Lucas Henrique Telles, Fernando Freitas Portella, Elken Gomes Rivaldo.
Methodology: Lucas Henrique Telles, Fernando Freitas Portella, Elken Gomes Rivaldo.
Project administration: Lucas Henrique Telles, Fernando Freitas Portella, Elken Gomes
Rivaldo.
Software: Fernando Freitas Portella.
Supervision: Lucas Henrique Telles, Fernando Freitas Portella, Elken Gomes Rivaldo.
Validation: Lucas Henrique Telles, Fernando Freitas Portella, Elken Gomes Rivaldo.
Visualization: Lucas Henrique Telles, Fernando Freitas Portella, Elken Gomes Rivaldo.
Writing – original draft: Lucas Henrique Telles, Fernando Freitas Portella, Elken Gomes
Rivaldo.
Writing – review & editing: Lucas Henrique Telles, Fernando Freitas Portella, Elken Gomes
Rivaldo.

References
1. Klein MO, Schiegnitz E, Al-Nawas B. Systematic review on success of narrow-diameter dental implants.
Int J Oral Maxillofac Implants. 2014; 29 Suppl:43–54.
2. Vigolo P, Givani A, Majzoub Z, Cordioli G. Clinical evaluation of small-diameter implants in single-tooth
and multiple-implant restorations: a 7-year retrospective study. Int J Oral Maxillofac Implants. 2004; 19
(5):703–709. PMID: 15508986
3. Bae M-S, Sohn D-S, Ahn M-R, Lee H-W, Jung H-S, Shin I-H. Retrospective multicenter evaluation of
tapered implant with a sandblasted and acid-etched surface at 1 to 4 years of function. Implant Dent.
2011; 20(4):280–284. https://doi.org/10.1097/ID.0b013e318218123b PMID: 21778892
4. Andersen E, Saxegaard E, Knutsen BM, Haanaes HR. A prospective clinical study evaluating the safety
and effectiveness of narrow-diameter threaded implants in the anterior region of the maxilla. Int J Oral
Maxillofac Implants. 2001; 16(2):217–224. PMID: 11324210
5. Zinsli B, Sägesser T, Mericske E, Mericske-Stern R. Clinical evaluation of small-diameter ITI implants:
a prospective study. Int J Oral Maxillofac Implants. 2004; 19(1):92–99. PMID: 14982361
6. Allum SR, Tomlinson RA, Joshi R. The impact of loads on standard diameter, small diameter and mini
implants: a comparative laboratory study. Clin Oral Implants Res. 2008; 19(6):553–559. https://doi.org/
10.1111/j.1600-0501.2007.01395.x PMID: 18474061
7. Chiapasco M, Casentini P, Zaniboni M, Corsi E, Anello T. Titanium-zirconium alloy narrow-diameter
implants (Straumann Roxolid((R))) for the rehabilitation of horizontally deficient edentulous ridges: pro-
spective study on 18 consecutive patients. Clin Oral Implants Res. 2012; 23(10):1136–1141. https://doi.
org/10.1111/j.1600-0501.2011.02296.x PMID: 22092806
8. Gi B, Go G, Mokti M, Chf H, H-p W, Re J. Titanium-zirconium narrow-diameter versus titanium regular-
diameter implants for anterior and premolar single crowns: 1-year results of a randomized controlled
clinical study. J Clin Periodontol. 2013; 40(11):1052–1061. https://doi.org/10.1111/jcpe.12156 PMID:
24015975
9. Ebler S, Jung RE, Thoma DS, Thoma DS. Prospective randomized controlled clinical study comparing
two types of two-piece dental implants supporting fixed reconstructions–results at 1 year of loading. Clin
Oral Implants Res. 2016; 27(9):1169–1177. https://doi.org/10.1111/clr.12721 PMID: 26459570
10. King P, Maiorana FC, Luthardt DDSRG, Sondell K, Øland J. Clinical and Radiographic Evaluation of a
Small-Diameter Dental Implant Used for the Restoration of Patients with Permanent Tooth Agenesis
(Hypodontia) in the Maxillary Lateral Incisor and Mandibular Incisor Regions: A 36-Month Follow-Up. Int
J Prosthodont. 2016; 29(2):147–153. https://doi.org/10.11607/ijp.4444 PMID: 26929953
11. Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for
systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev. 2015; 4(1):1.
12. Ioannidis A, German O, Ronald E, Christoph HF, Goran I. Titanium-zirconium narrow-diameter versus
titanium regular- diameter implants for anterior and premolar single crowns: 3- year results of a

PLOS ONE | https://doi.org/10.1371/journal.pone.0225046 November 11, 2019 11 / 12

 Longevity and bone loss of narrow implants

randomized controlled clinical study. J Clin Periodontol. 2015; 42(11):1060–1070. https://doi.org/10.

1111/jcpe.12468 PMID: 26440201
13. de Souza AB, Sukekava F, Tolentino L, César-Neto JB, Garcez-Filho J, Araújo MG. Narrow- and regu-
lar-diameter implants in the posterior region of the jaws to support single crowns: A 3-year split-mouth
randomized clinical trial. Clin Oral Implants Res. 2018; 29(1):100–107. https://doi.org/10.1111/clr.
13076 PMID: 28994192
14. Santing HJ, Raghoebar GM, Vissink A, den Hartog L, Meijer HJ. Performance of the Straumann Bone
Level Implant system for anterior single-tooth replacements in aug- mented and nonaugmented sites: A
prospective cohort study with 60 consecutive patients. Clin Oral Implants Res. 2013; 24(8):941–948.
https://doi.org/10.1111/j.1600-0501.2012.02486.x PMID: 22540833
15. Saleh MHA, Ravidà A, Suárez-López Del Amo F, Lin GH, Asa’ad F, Wang HL. The effect of implant-
abutment junction position on crestal bone loss: A systematic review and meta-analysis. Clin Implant
Dent Relat Res. 2018; 20(4):617–633. https://doi.org/10.1111/cid.12600 PMID: 29575584
16. Di Girolamo M, Calcaterra R, Di Gianfilippo R, Arcuri C, Baggi L. Bone level changes around platform
switching and platform matching implants: A systematic review with meta-analysis. ORAL Implantol.
2016; 9(1):1–10.
17. Weber HP, Morton D, Gallucci GO, Roccuzzo M, Cordaro L, Grutter L. Consensus statements and rec-
ommended clinical procedures regarding loading protocols. Int J Oral Maxillofac Implants. 2009; 24
Suppl:180–3.
18. Nhan V Van, Son L Van, Tuan TA, Son NT, Hai TD, Lanh LD, et al. A New Technique in Alveolar Cleft
Bone Grafting for Dental Implant Placement in Patients With Cleft Lip and Palate. Cleft Palate Craniofac
J. 2018; 55(2):180–188. https://doi.org/10.1177/1055665617723633 PMID: 29351041
19. Pellicer-Chover H, Peñarrocha-Diago M, Aloy-Prosper A, Canullo L, Peñarrocha-Diago M, Peñarrocha-
Oltra D. Does Apico-Coronal Implant Position Influence Peri-Implant Marginal Bone Loss? A 36-Month
Follow-Up Randomized Clinical Trial. J Oral Maxillofac Surg. 2019; 77(3):515–527. https://doi.org/10.
1016/j.joms.2018.11.002 PMID: 30529378
20. Altuna P, Lucas-Taule E, Gargallo-Albiol J, Figueras-Alvarez O, Hernandez-Alfaro F, Nart J. Clinical
evidence on titanium-zirconium dental implants: a systematic review and meta-analysis. Int J Oral Max-
illofac Surg. 2016; 45(7):842–50. https://doi.org/10.1016/j.ijom.2016.01.004 PMID: 26852292
21. Alrabiah M. Comparison of survival rate and crestal bone loss of narrow diameter dental implants versus
regular dental implants: A systematic review and meta-analysis. J Investig Clin Dent. 2019; 10(1):
e12367. https://doi.org/10.1111/jicd.12367 PMID: 30414262
22. Esposito M, Grusovin MG, Maghaireh H, Worthington HV. Interventions for replacing missing teeth: dif-
ferent times for loading dental implants. Cochrane Database Syst Rev. 2013;(3):CD003878. https://doi.
org/10.1002/14651858.CD003878.pub5 PMID: 23543525
23. Schiegnitz E, Al-Nawas B. Narrow-diameter implants: A systematic review and meta-analysis. Clin Oral
Implants Res. 2018; 29 Suppl 16:21–40.
24. Leão RS, Moraes SLD, Vasconcelos BCE, Lemos CAA, Pellizzer EP. Splinted and unsplinted overden-
ture attachment systems: A systematic review and meta-analysis. J Oral Rehabil. 2018; 45(8):647–656.
https://doi.org/10.1111/joor.12651 PMID: 29761853
25. Galindo-Moreno P, Nilsson P, King P, Worsaae N, Schramm A, Padial-Molina M, et al. Clinical and
radiographic evaluation of early loaded narrow-diameter implants: 5-year follow-up of a multicenter pro-
spective clinical study. Clin Oral Implants Res. 2017; 28(12):1584–1591. https://doi.org/10.1111/clr.
13029 PMID: 28626888

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